N126

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Author:
khonka
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131610
Filename:
N126
Updated:
2012-02-07 21:11:43
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Module2
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Intra-op
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  1. Circulating Nurse
    coordiante, oversee and involved in pt's nursing care in OR. Her actions are vital to the smooth flow of pre, intra and after surgery.

    • Sets up the OR (equptment, supplies, blood, diagnosit, make sure everyting is in working order and safe to use, sets up OR table and everthing needed on that table for the patiet and pt's position,)
    • positions the patient, folley catheter, scub sirgical site.
    • _ Monitors traffic in the room
    • _ Assesses the amount of urine and blood loss
    • _ Reports findings to the surgeon and anesthesia provider
    • _ Ensures that the surgical team maintain sterile technique and a sterile field
    • _ Anticipates the patient's and surgical team's needs, providing supplies and equipment
    • _ Communicates information about the patient's status to family members during long or unique procedures

    Records everything about the surgery.

    With scrub nurse count the surgical equipment.
  2. Scrub Nurse
    • sets up the sterile field, drape the patient, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant.
    • Throughout the surgical procedure, the scrub person (with the circulating nurse) maintains an accurate count of sponges, sharps, instruments, and amounts of irrigation fluid and drugs used.
  3. Patient safety and dignity during surgery
    The patient is unable to protect himself or herself during surgery; protection is provided by all members of the surgical team. The OR layout helps prevent infection by reducing contaminants through air exchanges in the room, maintaining recommended temperature and humidity levels, and limiting the traffic and activities in the OR. Safety straps are used for the patient, and the operating bed is locked in place. Blankets or warming units are used to prevent hypothermia, and interventions are used to prevent skin breakdown.

    • Electrical sefety, steralized and working equipment
    • The scrub and circulating nurses together ensure a correct count of surgical instruments, sharps, and sponges. Counts are performed before the procedure, during the procedure as items are added or at the time personnel are relieved from that assignment, at closure of the first layer of the surgical wound, and immediately before complete skin closure.

    Fire prevention by keeping room temp and humidity withing specific range.
  4. Aseptic techniques used in the OR
    • Mask, head cover and shoe covers
    • Surgical scrub (of heands and arms) - animicrobial solution is used. Plain or antimicrobial soap is used for washing hands immediately before the surgical scrub. Scrub from fingertips to elbows for 3 -5 min. Rinse. Position arms so that water runs off.
    • Then with hands held above weist line go into OR and dry with sterile towel.
    • This person than assisted into a sterile gown, then gloves.
    • Back of the gown is not sterile
    • Sleaves of the gown are sterile from 2 in above the elbove to cuff.
  5. Anasthesia
    is an induced state of partial or total loss of sensation, occurring with or without loss of consciousness. The purpose of anesthesia is to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some cases, achieve a controlled level of unconsciousness.
  6. General anasthesia
    2 kind: Inhalation and Intravenous (look at the slide for description and comon agents)

    emergence: recovery from anasthesia
  7. 4 stages of general anasthesia
    Stage 1: (analgesia and sedaton, relexation)

    • begins with induction and ends ith loss of consciousness.
    • Patient feels drowsy and dizzy, has a reduced sensation to pain, and is amnesic.
    • Hearing is exaggerated.

    • Stage 2: (excitement, delirium)
    • Begins with loss of consiousness and end with relaxation, regular breathing, and loss of the eyelid reflex.
    • Patient may have irregular breathing, increased muscle tone, and involuntary movement of the extremities.
    • Laryngospasm or vomiting may occur
    • Patient is susceptible to extenral stimuli

    Stage 3: (operative anasthesia)

    • Begins with generalized muscle relaxation and end with loss of reflexes and depresion of vital funcions.
    • Jaw is relaxed, breahing quite and regular
    • cannot hear
    • sensations (to pain) lost

    • Stage 4: Danger
    • begins with depression of vital functions and ends with respiratory failure, cardiac arrest, and possbile death
    • Respiratory muscles are peralized; apnea occurs
    • pupils are fixed and dilated.
  8. Manifestations of Malignat hyperthermia and intervensions
    Manifestations include tachycardia, dysrhythmias, muscle rigidity (especially of the jaw and upper chest), hypotension, tachypnea, skin mottling, cyanosis, and myoglobinuria (presence of muscle proteins in the urine). The most sensitive indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation. Another early indication is sinus tachycardia. Extremely elevated temperature, as high as 111.2° F (44° C), is a late sign of MH.

    • Intervensions: Dantrolene sodium, a skeletal muscle relaxant.
    • MH cart containing drugs for management (normal saline, dantrolene, sodium bicarbonate, insulin, 50% dextrose, and calcium chloride), a protocol card listing interventions, and the MH hotline number. Additional nursing support is needed during this true perioperative emergency.
  9. Potential adverse reactions and complications of anasthetic agents
    • Local anasthetics: lidocane, bupivacane, mercaine. Stop axonal conductionby blocking sodium channels in the axonal membrane. Recall that propagation of an action potentila requires movementof sodium ions from outside the axon to theinside. Usually administered with epineprhine(vasoconstrictor) it decreases local blood flow and thereby delays systemic absorption which prolongs anasthesia and reduces the risk of toxicity.
    • Adverse effects:CNS ecitation followed by deression. In heart - bradychardia, heart block, redued contractile forece, cardiac arrest. Anasthetis relax vascular smooth muscle - hypotension.

    • Analgesia- loss of sensibility to pain. Anasthesia - not only loss of pain but loss of all other sensations as well.
    • General anasthetics: 1) Inhalation anasthetics - Halothane - used with thiopental to prolong anasthesia to 1 hr. weak analgesic. and muscle relaxent but not adequate for surgery.
    • Shivering common postoperatively
    • Can induce malignant hyperthermia*
    • Hypotension and bradycardia may occur
    • Can increase dysrhythmias
    • Can cause permanent liver damage (rare).
    • Nitrous oxide - analgesic
    • Relatively weak anesthetic agent, bot strong analgesic.
    • May produce hypoxia if the concentration is high
    • Needs addition of other agents for longer procedures
    • surgery
    • CNS depresants - allowes a reduction in anasthetic dosage (barbiturates, benodiazepens, alchohols).
    • CNS stimulants(amphetamines, cocaine) increases the required dose of anesthetic.

    • Preanesthetic medications are administered for three main purposes: (1) reducing anxiety, (2) producing perioperative amnesia, and (3) relieving preoperative and postoperative pain. In addition, suppress: excessive salivation, excessive bronchial secretion, coughing, bradycardia, and vomiting.
    • Pancuronium- skeletal muscle relaxent a neuromascular blocker. Adverse effects -nerumascular blocking agent prevent contraction of all skeletal muscles (diaphgragm and other muscles of respiration). Pt require mechanical support of ventilation. May have reduced respiratory capacity after surgery
    • 2) Injectable anasthetics: Thiopental sodium -short-acting barbiturate produces unconsciousness. Causes cardio and resp depression. IF administered too rapidly may cause apnea.
    • Midaxolam - (bendodiazopines) used for induction of anesthesia and to produce conscious sedation. Can cause cardiorespiratory effects.
    • Propofol - sedative hepnotic used for induction and maintenance of anesthesia. Respiratory depression and hypotension. High risk for bacterial infection due to its mixture that is perfect for growth and it can cause sepsis and death. IV site pain.
    • Ketamine - causes dissociative anesthesia where pt feels dissociated from his or her environment. Adverse reactions - hallucinations, disturbingdreams, delirium.


    The agents used to achieve full anasthesia 1. short-acting barbitrates(for induction of anesthesia) 2. neuromuscular blocking agents (for muscle relexation) 3. opioids and nitrous oxide (for analgesia).
  10. How to reduce pt's and family's anxiety
    • Use a calm, reasuring approach
    • explain all procedures, including sensations likely to be expereinced during the srugical procedure
    • Provide accurate factual information about the surgery
    • Maintain eye contact with patient, deep breathing
    • Stay with pt and provide assurance of safety and security during periods of anxiety
    • Listen to the patient's conerns
    • Administer meds as appropriate to reduce anxiety.
  11. Anathesia overdose
    can occur if the patient's metabolism and drug elimination are slower than expected. This is more likely to occur in patients who are older or who have liver or kidney problems. Other drugs (e.g., antihypertensives) also alter metabolism, and interactions can occur between the anesthetic and the patient's regular drugs. Accurate information about the patient's height, weight, and medical history, especially liver and kidney function, is vital in determining the anesthetic type and dosage.
  12. Regional anasthesia
    Rapid unconsciousness and loss of sensation. Inhales or intravenous. Medications depress patient's CNS and relax the musculature - muscle relaxants, paralyzing agents, narcotics, barbiturates, and inhaled gases.

    • Advantages: anasthesia can be adjusted without inturapting the procesudre.
    • Disadvantages: Mechanical ventilation is needed - this effects predispose the pt to pneumonia and thrombophlebitis. Risk for death, heart attack, stroke, laignat hyperthermia.
    • Sore throat, nausea and vomiting, headache, ucontrollable shivering, and confusion.
  13. Local and Regional Anasthesia
    • Briefly disrupts sensory nerve impulse transmission from a specific body area or region.
    • Because the gag and cough reflexes remain intact, the risk for aspiration is low.
    • Often supplemented with sedatives, opioid analgesics, or hypnotics to reduce anxiety and increase comfort.

    Local: is delivered topically and by local infiltration (injected directly into the tissue around an incision, wound, or lesion). Sometimes when the term local is used, it means any form of anesthesia that is not general anesthesia.

    Regional: is a type of local anesthesia that blocks multiple peripheral nerves in a specific body region. It may be used when general anesthesia cannot be used because of medical problems, when the patient has had adverse reactions to general anesthesia, when the patient has a preference and a choice is possible. Types of regional anesthesia include field block, nerve block, spinal, and epidural. Administered by infiltration of the surgical site with local anasthetics.
  14. Conscious Sedation
    • Conscious sedation is the IV delivery of sedative, hypnotic, and opioid drugs to reduce the level of consciousness but allow the patient to maintain a patent airway and to respond to verbal commands. The amnesia action is short, and the patient usually has a rapid return to ADLs.
    • Conscious sedation is used for endoscopy, cardiac catheterization, closed fracture reduction, cardioversion, and other special but short procedures.
    • The nurse monitors the patient during and after the procedure for response to the procedure and the drugs. The airway, level of consciousness, oxygen saturation, ECG status, and vital signs are monitored every 15 to 30 minutes until the patient is awake and oriented and vital signs have returned to baseline levels
  15. Nurse's role in patient identity and correct surgical procedure.
    • The nurse verifies the patient's identity with two types of identifiers (name, birth date, medical record number, or social security number).
    • The nurse always validates identification using the medical record and identification bracelet and by asking the patient or family.After completing the identification process, the nurse validates that the surgical consent form has been signed and witnessed. The nurse asks, “What kind of operation are you having today?” to ascertain that the patient's perception of the procedure, the operative permit, and the operative schedule are the same. When the procedure involves a specific site, validating the side on which a procedure is to be performed (e.g., for amputation, cataract removal, hernia repair) is the responsibility of each health care professional before and at the time of surgery. Facilities usually have the patient and/or nurse initial the correct surgical site.
    • Before proceeding, each health care professional thoroughly investigates any discrepancy and notifies the surgeon and anesthesia provider.
    • The nurse asks the patient about any allergies and determines whether autologous blood was donated. A red allergy bracelet on the patient's wrist and the medical record must be verified with what has been communicated.

    • The nurse checks the patient's attire to ensure adherence with facility policy. Dentures and dental prostheses (e.g., bridges, retainers), jewelry (including body piercing), eyeglasses, contact lenses, hearing aids, wigs, and other prostheses are removed. Denture removal before anesthesia is controversial.
    • Circulating nurse ans anasthesiologis review pt's medical record in holding area or OR.
    • Advanced directive and do not recucitate orders.
    • The nurse asks about allergies and previous reactions to anesthesia or blood transfusions. Allergies to iodine products or shellfish indicate a risk for a reaction to the agents used to clean the surgical area. Latex allergies are assessed with all patients.
    • Lab and diagnositic testing results obtained 24-48 hours prior to surgery.
  16. Interventions during he intraopretaive phase
    Prevent injury from positioning during surgery (prevent pressure ulcers by correct positioning), pads and gel peds put under the patient and skin is assessed for bursing or other skin damage and puts extra pedding in thouse areas.
  17. Various positions may be put in for a specific surgical procedure and the effects such positions canhave on the patient.
    • The dorsal recumbent, prone(nazhivote), lithotomy(u ginecologa), and lateral(na boku) positions are most often used for surgery.
    • Patient is positions slowely after anathesia to prevent hypotension from dilated vesseles.
    • Proper positions is insured by assessing for:
    • _Anatomic alignment
    • _ Interference with circulation and breathing
    • _ Protection of skeletal and neuromuscular structures
    • _ Optimal exposure of the operative site and IV line
    • _ Adequate access to the patient for the anesthesia provider
    • _ The patient's comfort and safety
    • _ Preservation of the patient's dignity
    • For example, patients in the lithotomy position may develop leg swelling, pain in the legs or back, reduced foot pulses, or reduced sensation from compression of the peroneal nerve. The nurse ensures proper padding and position changes at regular intervals. Throughout the surgery, the nurse prevents obstruction of circulation, respiration, or nerve conduction caused by tight straps, poorly placed pads and pillows, or the position of the bed
  18. Factors predisposing the patient to infection
    pre-existing health problems such as diabetes mellitus, immune deficiency, obesity, and renal failure.
  19. Sterilization
    means destroying all livingorgnisms and bacterial spores. All items that invade human tissue where bacteria are not commonly found shold be sterilized.
  20. Disinfection
    does not kill spores and only insures the reduction in the level of disease-causing organisms. High-level disinfection is adequate when an item is going inside the body where the patient has resident bateria or normal flora (GI and respiratory tract). As with sterilization, no high-level disinfection can occure without first cleaning the item.
  21. Immediate assessment of a pt in the post anesthesia room
    • LOC, BP, temp, pulse, resp, O2 sat, but the most important one is respiratory. examine the surgical signes for bleeding.
    • Criteria for dischage from PACU - stable vital signes, normal body temp, no over bleeding, returnto gag, cough, and swallow reflexes, and teh ability to take liquides. Then pt is discharged by anesthesie provider.
  22. Potantial postoperative complications
    at risk for pneumonia, shock, cardiacarrest,respiratory arrest, dep vein thrombosis, and GI bleeding.

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